1
|
Vozoris NT, Fu L, Austin PC, Stephenson AL, Gill SS, Chow CW, Ryan CM, To T. Comparative Safety Analysis of Nabilone Versus Opioids: A Population-Based Cohort Study. J Gen Intern Med 2024:10.1007/s11606-024-08978-2. [PMID: 39141203 DOI: 10.1007/s11606-024-08978-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Accepted: 07/24/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Some have advocated that nabilone be used rather than opioids to manage chronic, noncancer pain, since the former drug may have a better safety profile. OBJECTIVE We compared the safety of incident nabilone use relative to incident opioid use with respect to multiple clinically important outcomes. DESIGN A population-based, retrospective cohort study. SETTING Province of Ontario, Canada. PARTICIPANTS Persons aged 12 years and older, diagnosed with a musculoskeletal condition within the past 3 years prior to the index date. EXPOSURES Incident nabilone use, with incident opioid use serving as the reference group. MEASUREMENTS Within 3 months following the index date, we separately evaluated for pneumonia, motor vehicle accidents, falls or fractures, mental and behavioral disorder due to psychoactive substance use, and all-cause mortality. RESULTS A total of 18,863 incident nabilone users were propensity score matched to an equal number of opioid users. In the overall matched analysis, incident nabilone users vs. incident opioid users had significantly lower rates of pneumonia (hazard ratio [HR] 0.78, 95% CI 0.63-0.96), falls or fractures (HR 0.56, 95% CI 0.50-0.64), and all-cause mortality (HR 0.79, 95% CI 0.65-0.95), but significantly higher rate of mental or behavioral disorder (HR 2.23, 95% CI 1.45-3.43). There was no significant difference between groups with respect to rate of motor vehicle accidents. LIMITATIONS Unmeasured confounding may have influenced results. CONCLUSIONS While usage of nabilone relative to opioids was associated with reduced rates of pneumonia, falls or fractures, and all-cause mortality, it was simultaneously associated with an increased rate of adverse mental health outcomes. This picture of mixed safety results raises concerns with the policy approach of broadly substituting use of opioids with nabilone. FUNDING SOURCE Ontario Ministry of Health.
Collapse
Affiliation(s)
- Nicholas T Vozoris
- Division of Respirology, Department of Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada.
- Keenan Research Centre in the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada.
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
- Airways Disease Group, Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
- ICES, V Wing, V1-06, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.
| | - Longdi Fu
- ICES, V Wing, V1-06, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
| | - Peter C Austin
- ICES, V Wing, V1-06, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Anne L Stephenson
- Division of Respirology, Department of Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
- Keenan Research Centre in the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sudeep S Gill
- ICES, V Wing, V1-06, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
- Providence Care Hospital, 752 King Street West, Kingston Ontario, K7L 4X3, Canada
| | - Chung-Wai Chow
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Airways Disease Group, Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, Toronto General Hospital, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada
| | - Clodagh M Ryan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Airways Disease Group, Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, Toronto General Hospital, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada
| | - Teresa To
- Airways Disease Group, Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, V Wing, V1-06, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
| |
Collapse
|
2
|
Bhagianadh D, Arora K. Legalization of Medical Cannabis and Site of Death: Evidence From National Vital Statistics Mortality Data. J Appl Gerontol 2021; 41:806-816. [PMID: 34930063 DOI: 10.1177/07334648211058720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We examined whether Medical Marijuana Legislation (MML) was associated with site of death. Using state-level data (1992-2018) from the National Vital Statistics System (NVSS), we employed difference-in-differences method to compare changes in death rate among older adults at four sites-nursing home (NH), hospital, home, hospice/other-over time in states with and without MML. Heterogeneity analyses were conducted by timing of MML adoption, and by decedent characteristics. Results show a negative association between MML implementation and NH deaths. Among early adopters (states with weakly regulated programs) and decedents with musculoskeletal disorders, there was a positive association between MML implementation and hospital deaths, whereas among late adopters (states with "medicalized" programs), there was a positive association between MML implementation and hospice deaths. Decline in NH deaths may reflect increased likelihood of transfers due to threat of Federal enforcement, penalties for poor outcomes, and liability concerns. Future studies should examine these associations further.
Collapse
Affiliation(s)
- Divya Bhagianadh
- Department of Health Management and Policy, University of Iowa, Iowa City, IA, USA
| | - Kanika Arora
- Department of Health Management and Policy, University of Iowa, Iowa City, IA, USA
| |
Collapse
|
3
|
Redelmeier DA, Ng K, Thiruchelvam D, Shafir E. Association of socioeconomic status with medical assistance in dying: a case-control analysis. BMJ Open 2021; 11:e043547. [PMID: 34035092 PMCID: PMC8154947 DOI: 10.1136/bmjopen-2020-043547] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Economic constraints are a common explanation of why patients with low socioeconomic status tend to experience less access to medical care. We tested whether the decreased care extends to medical assistance in dying in a healthcare system with no direct economic constraints. DESIGN Population-based case-control study of adults who died. SETTING Ontario, Canada, between 1 June 2016 and 1 June 2019. PATIENTS Patients receiving palliative care under universal insurance with no user fees. EXPOSURE Patient's socioeconomic status identified using standardised quintiles. MAIN OUTCOME MEASURE Whether the patient received medical assistance in dying. RESULTS A total of 50 096 palliative care patients died, of whom 920 received medical assistance in dying (cases) and 49 176 did not receive medical assistance in dying (controls). Medical assistance in dying was less frequent for patients with low socioeconomic status (166 of 11 008=1.5%) than for patients with high socioeconomic status (227 of 9277=2.4%). This equalled a 39% decreased odds of receiving medical assistance in dying associated with low socioeconomic status (OR=0.61, 95% CI 0.50 to 0.75, p<0.001). The relative decrease was evident across diverse patient groups and after adjusting for age, sex, home location, malignancy diagnosis, healthcare utilisation and overall frailty. The findings also replicated in a subgroup analysis that matched patients on responsible physician, a sensitivity analysis based on a different socioeconomic measure of low-income status and a confirmation study using a randomised survey design. CONCLUSIONS Patients with low socioeconomic status are less likely to receive medical assistance in dying under universal health insurance. An awareness of this imbalance may help in understanding patient decisions in less extreme clinical settings.
Collapse
Affiliation(s)
- Donald A Redelmeier
- Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Kelvin Ng
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Deva Thiruchelvam
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Psychology, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Eldar Shafir
- Public Policy, Princeton University, Princeton, New Jersey, USA
- Psychology, Princeton University, Princeton, New Jersey, USA
| |
Collapse
|
4
|
Vozoris NT, Pequeno P, Li P, Austin PC, Stephenson AL, O'Donnell DE, Gill SS, Gershon AS, Rochon PA. Morbidity and mortality associated with prescription cannabinoid drug use in COPD. Thorax 2020; 76:29-36. [DOI: 10.1136/thoraxjnl-2020-215346] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/11/2020] [Accepted: 08/25/2020] [Indexed: 01/18/2023]
Abstract
IntroductionRespiratory-related morbidity and mortality were evaluated in relation to incident prescription oral synthetic cannabinoid (nabilone, dronabinol) use among older adults with chronic obstructive pulmonary disease (COPD).MethodsThis was a retrospective, population-based, data-linkage cohort study, analysing health administrative data from Ontario, Canada, from 2006 to 2016. We identified individuals aged 66 years and older with COPD, using a highly specific, validated algorithm, excluding individuals with malignancy and those receiving palliative care (n=185 876 after exclusions). An equivalent number (2106 in each group) of new cannabinoid users (defined as individuals dispensed either nabilone or dronabinol, with no dispensing for either drug in the year previous) and controls (defined as new users of a non-cannabinoid drug) were matched on 36 relevant covariates, using propensity scoring methods. Cox proportional hazard regression was used.ResultsRate of hospitalisation for COPD or pneumonia was not significantly different between new cannabinoid users and controls (HR 0.87; 95% CI 0.61–1.24). However, significantly higher rates of all-cause mortality occurred among new cannabinoid users compared with controls (HR 1.64; 95% CI 1.14–2.39). Individuals receiving higher-dose cannabinoids relative to controls were observed to experience both increased rates of hospitalisation for COPD and pneumonia (HR 2.78; 95% CI 1.17–7.09) and all-cause mortality (HR 3.31; 95% CI 1.30–9.51).ConclusionsNew cannabinoid use was associated with elevated rates of adverse outcomes among older adults with COPD. Although further research is needed to confirm these observations, our findings should be considered in decisions to use cannabinoids among older adults with COPD.
Collapse
|